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Multimodal COVID-19 Control
The concept of multimodal control of COVID-19 was first introduced in July 2021 as a long-term means of controlling the spread of COVID-19. The approach employs multiple rings of protection to contain the spread of SARS-CoV-2 and its variants and eliminate COVID-19 as a major life-threatening disease.

Given the likelihood of COVID-19 becoming endemic the strategy employs the world’s rapidly growing arsenal of vaccines and antiviral drugs along with public health measures to contain the spread of disease. The Brookings Institution published a Global Working Paper which described the proposal in detail.

Vaccines
Vaccines make up the first ring of defense in the multimodal strategy. The current generation of vaccines, especially the mRNA vaccines produced by Pfizer/BioNTech and Moderna, are effective against the original wild-type virus and many of its known variants. Clinical trials showed these mRNA vaccines were initially around 95% effective at preventing infection and severe disease. As new variants have emerged, effectiveness of each vaccine has varied, with current estimates for the mRNA vaccines suggesting they are at least 64% effective against infection and may be even more effective against severe disease shortly after vaccination.

While vaccines may be highly effective at preventing disease, they are not equally effective at preventing infection. Recent studies have shown that those who are vaccinated but still become infected can carry the same amount of virus in their systems as those who are unvaccinated and infected. This means that while vaccines may protect those who are vaccinated from severe illness, they may not protect those around them from infection.

As a study from the Scientific Advisory Group for Emergencies in the UK put it, vaccines that prevent severe disease are critical to our efforts today, but a longer term solution requires vaccines that also induce high and durable levels of mucosal immunity in order to reduce infection of and transmission from vaccinated individuals. In addition, two other types of third generation vaccines may provide more promising solutions: vaccines that may allow for easier manufacturing and distribution of doses, such as single dose vaccines, non-injectable vaccines or double dose vaccines that don’t require cold chain storage; and vaccines that could protect against all SARS-CoV-2 variants and possibly even other coronaviruses, called mosaic vaccines.

Antiviral Treatment and Prophylaxis
The next ring of defense are antiviral drugs. As a treatment, these drugs could have a profound effect for immunocompromised patients with chronic viremia. Studies have shown that even after months of living with the virus, antiviral treatments can clear the viremia and eliminate symptoms of the disease, though drug resistance is a potential issue. Antivirals could also be an effective treatment for the average person infected by SARS-CoV-2 if administered early enough in the course of the disease. However, studies show that by the time symptoms of Covid-19 appear, it may already be too late for antivirals to help stop the spread of the virus in the body. This means that if people aren’t testing themselves regularly, they may not know they’re infected in time to take the drugs and have them be infected.

Antivirals could also be used prophylactically, though the current generation of drugs are expensive to produce and cumbersome to administer, requiring an intravenous infusion in a clinical setting. Next generation antivirals in pill form, however, could be used prophylactically in communal settings, such as schools, businesses, and long-term care settings. If one among many tests positive for Covid-19, those around them could take a pill to prevent infection. Cocktails of antiviral drugs can work on multiple targets at the same time and make it harder for the virus to develop resistance.

The advent of prophylactic drugs in pill form would have an impact on public health containment efforts, as described in the section below. As opposed to test, trace and quarantine to avoid spreading further infection, people may be encouraged to test, trace, and prophylactically prevent. Antiviral prophylaxis may also help reopen borders and reignite global travel, as drugs could be taken prior to and during travel, limiting the need for extended quarantines for travelers upon arrival in a new country or region.

Public Health Containment
Public health strategies like mask wearing, social distancing, testing, contact tracing, isolation, and quarantine have been critical methods of protection in the face of nearly every infectious disease in recent history and make up the third ring of defense. These strategies may be enhanced by drugs and vaccines that can help reduce the burden of quarantine, ease the scope of new outbreaks and, as found in a recent modeling study, improve the world’s ability to contain and control vaccine-resistant strains.

Some countries, like Australia, China, New Zealand, Singapore, and Taiwan, used these methods to nearly eliminate the virus within their borders, however new more transmissible variants have mutated to ever-increasing levels of transmissibility to overcome even the strictest adherence to these public health standards. A study out of Australia found that a Melbourne man quarantined in a monitored facility on the same floor as another traveler who eventually tested positive for the highly infectious Kappa variant was infected despite not having any direct contact with the other traveler; that outbreak eventually exposed more than 17,000 people to the virus and which could only be contained with another round of lockdowns.

This reinforces the idea that public health containment is an important strategy to contain the virus but one that can’t be used alone. Other surveillance efforts that can identify community outbreaks and contain their spread, like the CDC’s National Wastewater Surveillance System. If communities can identify an outbreak early, people in those communities can be isolated and given priority access to vaccines or antiviral prophylactic pills, when they become available.

Global Containment
The final barrier around COVID-19 is a global ring of protection, with an international community working together to further SARS-CoV-2 fundamental research, new medical solutions, global disease surveillance, and universal access to tests, treatments and vaccines.

The Access to COVID-19 Tools (ACT) Accelerator and its vaccines pillar, COVAX, is a global philanthropic partnership to accelerate the development and production of COVID-19 tests, treatments and vaccines (via COVAX) and access to them. The global community is also working to intensify global disease surveillance to help identify new outbreaks, especially ones caused by highly infectious variants that can quickly take hold and spread. This means all countries must enhance surveillance efforts, increase sequencing of the virus across all communities, and develop a near real-time method of sharing the data broadly.

Scientists, researchers, and vaccine and drug manufacturers are required to quickly determine how vaccines and treatments fare against each new variant and what can be done to mitigate their spread and reduce the likelihood of new variants emerging. This means significantly expanding the current understanding of SARS-CoV-2 and its molecular biology.

In the Media
Multimodal COVID-19 control has been spoken about widely in the media, including in the Washington Post, CNN, The Jordan Times, and Forbes.